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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 65-68

Antibiotics in endodontics

1 Department of Conservative Dental Science, Vice Dean of Academic Affairs, College of Dentistry, King Khalid University, Abha, Saudi Arabia
2 Department of Oral and Maxillofacial Science, Vice Dean of Academic Affairs, College of Dentistry, King Khalid University, Abha, Saudi Arabia
3 Department of Restorative Dental Science, Vice Dean of Academic Affairs, College of Dentistry, King Khalid University, Abha, Saudi Arabia

Date of Submission19-Oct-2019
Date of Acceptance05-Nov-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Dr. Mubashir Baig Mirza
Department of Restorative Dental Science Vice Dean of Academic Affairs, College of Dentistry, King Khalid University, Abha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_52_19

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The main causative factor in the pathogenesis and progression of pulp/periapical diseases has been the bacteria in the root canal system (RCS). The removal of these bacteria from the RCS and establishing an environment where the remaining bacteria cannot survive has been the primary aim of endodontic treatment. This can be achieved by using antibiotics which can be used in endodontic treatment as locally, systemically, and prophylactically. This present review will elaborate upon the use of antibiotics in the field of endodontics.

Keywords: Antibiotics, endodontic infections, microorganism, MTAD, triple antibiotic paste

How to cite this article:
Mirza MB, Alhedyan FS, Alqahtani AM. Antibiotics in endodontics. J Dent Res Rev 2019;6:65-8

How to cite this URL:
Mirza MB, Alhedyan FS, Alqahtani AM. Antibiotics in endodontics. J Dent Res Rev [serial online] 2019 [cited 2022 Dec 1];6:65-8. Available from: https://www.jdrr.org/text.asp?2019/6/3/65/273909

  Introduction Top

The incidence of microorganisms in the progression of pulp and periapical diseases is a well-known fact. Complete removal of these microorganisms from the infected root canals is a complicated task. The bacteria in primary endodontic infections are mixed in origin, but usually are Gram-negative anaerobic rods, whereas Enterococcus faecalis is associated with secondary infection.[1],[2] The main goal of endodontic treatment is removal of these microorganisms and their by-products from the root canal space by using various antimicrobial agents to provide an environment free of microorganisms[3],[4] Since penicillin discovery by Alexander Fleming in 1928, health care has entirely been revolutionized with the introduction of antibiotics. Antibiotics are prescribed in numerous disciplines of medicine and dentistry since decades now.[5] The local application of antibiotics is an effective mode of disinfection in endodontics because systemic antibiotics fail to reach the necrotic pulp.[6],[7] The present article aims to elaborate on the use of antibiotics in the field of endodontics.

  Uses of Antibiotics in Endodontics Top

Topical use of antibiotics

In 1951, Grossman – Father of Endodontics – proposed the use of polyantibiotic paste – in a combination of penicillin, streptomycin, bacitracin, and caprylate sodium suspended in silico n vehicle to be used as an antibiotic locally.[8] The topical antibiotic use has been proposed for several endodontic treatments.

Locally used antibiotic agents in endodontics are shown in [Figure 1].
Figure 1: Locally used antibiotic agents in endodontics

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Antibiotics and their uses are shown in [Figure 2].
Figure 2: Antibiotics and their uses

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The rationale for local application of antibiotics

Systemic antibiotics as an adjunct appear to be clinically effective in various surgical and nonsurgical endodontic cases. Their administration comes with the potential risk of adverse systemic effects and various side effects and the development of resistant strains of microbes. In addition, applying antibiotics systemically relies on patient compliance with proper dose regimen and absorption through the gastrointestinal tract and distribution through circulation to the infected site. Therefore, a normal blood supply to the infected area is needed which is no longer the case for teeth with a necrotic pulp, a pulpless and infected root canal system (RCS), or a root-filled tooth that becomes infected. Hence, in RCS, local application of antibiotics is a more effective mode for delivering the drug.[9]

Pulp capping

In pulp-capping procedures, a protective agent is applied to an exposed pulp (direct capping) or a thin layer of dentin is retained over a nearly exposed pulp (indirect capping), which allows the pulp to recover and maintain its normal status and function. There is no scientific evidence supporting the use of antibiotics in pulp-capping procedures.[10]

Antibiotics used during root canal treatment

As the systemic usage of antibiotics has shown to be with adverse effects, antibiotics are applied locally in root canal treatment, that is, within the canal system.[11] Poly-antibiotic paste was the first local antibiotic used. Sato et al.[12] used a mixture of minocycline, a tetracycline, with ciprofloxacin and metronidazole. When placed in root canals and previously irrigated ultrasonically, it will penetrate through the dentine and has shown antibacterial efficacy.

  Root Canal Irrigants Top


MTAD is a mixture of 3% doxycycline, citric acid, and a detergent polysorbate 80. The potency of MTAD in the disinfection of root canals has been reported in previous studies. Torabinejad and Shabahang have shown that MTAD can remove the smear layer without affecting the structure of dentinal tubules and is effective against Enterococcus faecalis.[13] Newberry et al. evaluated the antimicrobial efficacy of MTAD against various strains of E. faecalis. In the present study, MTAD was used as a final rinse for 5 min after initial irrigation of the canals with 1.3% NaOCL. This showed complete elimination of seven out of eight strains of bacteria.[14] Tang et al. showed that the effectiveness of MTAD against E. faecalis can be enhanced by adding nisin. MTAD comes as a powder–liquid system. Liquid contains 4.25% citric acid and 0.5% polysorbate 80 (Tween 80). Powder contains broad-spectrum antibiotic, 3% doxycycline hyclate. Doxycycline has bacteriostatic action which is advantageous, as in the absence of bacterial cell lysis, no endotoxin will be released and thus substantivity of doxycycline will have a prolonged antibacterial effect.[15]


TetraClean™ is a mixture of an antibiotic, an acid, and a detergent, but it differs from MTAD by the concentration of doxycycline (50 mg/ml) and the type of detergent polypropylene glycol. TeraClean is more effective than MTAD against the endodontic pathogen E. faecalis in the mixed species and planktonic culture in in- vitro biofilm. Giardino et al. also proved that TetraClean resulted in a high degree of biofilm disintegration on nitrate membrane filters when compared with MTAD and 5.25% NaOCL.[16]

  Intracanal Medicaments Top

The rationale of intracanal medicaments in modern endodontics is to reduce bacterial regrowth and possibly improve bacterial suppression, as shown in [Figure 3]. An intracanal medication can be advantageous and successfully used to eliminate the bacterial flora. Interappointment antimicrobial medication acts by inhibiting the proliferation of bacteria and further eliminates surviving bacteria, as well as minimizes ingress of pathogens through a leaking restoration.
Figure 3: Intracanal medicaments

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Ledermix® paste has been recommended as an intracanal medicament. Ledermix paste has been advocated as an initial dressing, particularly if the patient presents with endodontic symptoms.[17] It is a paste made up of corticosteroids and antibiotics. Ledermix paste contains triamcinolone acetonide as an anti-inflammatory agent, at a concentration of 1%. Ledermix paste is a nonsetting, water-soluble paste material for use as a root canal medicament or as a direct or indirect pulp-capping agent. Studies have shown that triamcinolone is released from Septomixine Forte (Septodont, Saint-Maur-des-foss_e, France) which is another commercial product for intracanal use. It contains two antibiotics, neomycin and polymyxin B sulfate, but its effect against endodontic flora is not better than that with calcium hydroxide.[17],[18]

Odontopaste® is a zinc oxide-based root canal paste with clindamycin hydrochloride 5% and 1% triamcinolone acetonide. It is bacteriostatic and prevents bacterial repopulation in the RCS. The steroid present in it reduces the postoperative pain and inflammation. Odontopaste itself contains 0.5% calcium hydroxide in it, hence mixing of an additional calcium hydroxide in Odontopaste is not recommended because it results in rapid loss or destruction of the steroid component in it. There is no significant improvement in antibacterial action in the calcium hydroxide combination or mixture when compared to calcium hydroxide alone.[19]

Antibacterial nanoparticles are microscopic particles in the range of 1–100. They have a unique antimicrobial activity and far lower propensity to induce the resistance of bacteria. Because of electrostatic interaction between positively charged nanoparticles and negatively charged bacterial cells, which leads to loss of membrane function, as shown in [Figure 4], they have the ability to eliminate biofilm bacteria, but this needs further improvement. Sealers loaded with nanoparticles have displayed better ability to diffuse antibacterial component deeper into the dentin. Studies have shown their role better as an intracanal medicament than as an irrigant.[20]
Figure 4: Mechanism of action of antibacterial nanoparticles

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  Regenerative Endodontic Procedures Top

It is a challenge to clinically treat an immature tooth with pulpal necrosis. Regenerative endodontic procedures play an important role in such scenarios, as shown in [Figure 5]. Chronic infection in the RCS can dramatically affect the success of regenerative procedure; thus, it must be suppressed by using adequate disinfection to disinfect the RCS in regenerative endodontics. Different medications have been previously tried. Approximately 51% of endodontists used a mixture of triple antibiotic of ciprofloxacin/metronidazole/minocycline at a ratio of 1:1:1, whereas around 37% of endodontists used Ca(OH)2.[21] Hoshino et al. introduced triple antibiotic paste (TAP) or “3Mix” which has been most widely used as an intracanal medicament in regenerative endodontic procedures. TAP is a combination of three antibiotics, namely minocycline, ciprofloxacin, and metronidazole. Metronidazole is a nitro imidazole compound, which is selectively toxic and effective against anaerobic organisms. Presence of redox protein reduces the nitro groups of this compound and generates free radicals that cause DNA damage and lysis of cell. Minocycline, primarily a bacteriostatic, inhibits protein synthesis by binding to 30S ribosome in susceptible organisms. Ciprofloxacin is a synthetic fluoroquinolone with rapid bactericidal action. It inhibits the enzyme bacterial DNA gyrase.[22],[23]
Figure 5: Regenerative endodontic procedures

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Medicated gutta percha

Howard Martin introduced medicated gutta percha. Tetracycline integrated Gutta Percha (TGP) contains 20% gutta-percha, 57% zinc oxide, 10% tetracycline, 10% barium sulfate, and 3% beeswax. The developers claim that the tetracycline in these gutta-percha cones remains inert until it comes in contact with tissue fluids, when it gets activated, and becomes available to inhibit any bacteria that remain in the root canal or those that enter the canal via leakage.[24],[25]

  Medicated Sealers Top

The addition of antibiotics into the root canal sealer is highly beneficial to prevent re-infection and exhibits antimicrobial property for a longer period of time. Hoelscher et al. found that amoxicillin, clindamycin, penicillin, and doxycycline were helpful in enhancing the antimicrobial efficacy of Kerr Pulp Canal Sealer™ against E. faecalis. One more study showed that addition of metronidazole, amoxicillin, and doxycycline to Kerr sealer with extended working time improved the apical sealing as well as antibacterial property.[26]

  Traumatic Injuries Top

Luxation injuries often cause pulp necrosis; thus, a precise treatment approach is very crucial. Severe luxation injuries result in damage to the apical neurovascular supply, which may result in tooth devitalization.[27] This may be destructive and result in inflammatory root resorption, in which removal of the inflammatory cells is needed. Dressing the root canal space with Ledermix combined with corticosteroid and tetracycline as well as triamcinolone results in high favorable healing rate.[28]

Avulsion can result in serious problem when not repositioned immediately. Pulp necrosis usually occurs after avulsion due to bacterial contamination. Application of topical antibiotic on replanted tooth after avulsion enhances healing. Hinckfuss and Messer, 2009,[29] reported that topical use of antibiotics when compared to systemic use has been reported to be more beneficial. In addition, there is evidence that antibiotics play an important role in controlling infection and reducing the risk of inflammatory resorption.[30]

  Conclusion Top

Safe use of antibiotics has revolutionized the treatment of various diseases. Use of antibiotics, both systemic and topical, is common in the endodontic treatment, particularly for patients with pain or swelling. The use of antibiotic-containing dental agents should be carefully justified, in order to avoid a bacterial resistance.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Siqueira JF, Rôças IN. Microbiology and treatment of endodontic infections. In: Hargreaves KM, Cohen S, Berman LH, editors. Cohen's Pathways of the Pulp. 11th ed. St Louis: Mosby Elsevier; 2016. p. 599.  Back to cited text no. 1
Dahlen G. Culture-based analysis of endodontic infections. In: Fouad AF, editor. Endodontic Microbiology. 2nd ed. Ames (IA): Wiley-Blackwell; 2017. p. 51-81.  Back to cited text no. 2
Rôças IN, Siqueira JF Jr. Detection of novel oral species and phylotypes in symptomatic endodontic infections including abscesses. FEMS Microbiol Lett 2005;250:279-85.  Back to cited text no. 3
Ricucci D, Siqueira JF Jr. Biofilms and apical periodontitis: Study of prevalence and association with clinical and histopathologic findings. J Endod 2010;36:1277-88.  Back to cited text no. 4
Abbott PV. Selective and intelligent use of antibiotics in endodontics. Aust Endod J 2000;26:30-9.  Back to cited text no. 5
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Gilad JZ, Teles R, Goodson M, White RR, Stashenko P. Development of a clindamycin-impregnated fiber as an intracanal medication in endodontic therapy. J Endod 1999;25:722-7.  Back to cited text no. 7
Grossman LI. Polyantibiotic treatment of pulpless teeth. J Am Dent Assoc 1951;43:265-78.  Back to cited text no. 8
Mohammadi Z. An update on the antibiotic-based root canal irrigation solutions. Iran Endod J 2008;3:1-7.  Back to cited text no. 9
Cannon M, Cernigliaro J, Vieira A, Percinoto C, Jurado R. Effects of antibacterial agents on dental pulps of monkeys mechanically exposed and contaminated. J Clin Pediatr Dent 2008;33:21-8.  Back to cited text no. 10
Mohammadi Z, Abbott PV. Antimicrobial substantivity of root canal irrigants and medicaments: A review. Aust Endod J 2009;35:131-9.  Back to cited text no. 11
Sato I, Ando-Kurihara N, Kota K, Iwaku M, Hoshino E. Sterilization of infected root-canal dentine by topical application of a mixture of ciprofloxacin, metronidazole and minocycline in situ. Int Endod J 1996;29:118-24.  Back to cited text no. 12
Shabahang S, Torabinejad M. Effect of MTAD on Enterococcusfaecalis-contaminated root canals of extracted human teeth. J Endod 2003;29:576-9.  Back to cited text no. 13
Newberry BM, Shabahang S, Johnson N, Aprecio RM, Torabinejad M. The antimicrobial effect of BioPure MTAD on eight strains of Enterococcusfaecalis: An in vitro investigation. J Endod 2007;33:1352-4.  Back to cited text no. 14
Tang G, Samaranayake LP, Yip HK. Molecular evaluation of residual endodontic microorganisms after instrumentation, irrigation and medication with either calcium hydroxide or septomixine. Oral Dis 2004;10:389-97.  Back to cited text no. 15
Giardino L, Ambu E, Savoldi E, Rimondini R, Cassanelli C, Debbia EA, et al. Comparative evaluation of antimicrobial efficacy of sodium hypochlorite, MTAD, and TetraClean against Enterococcus faecalis biofilm. J Endod 2007;33:852-5.  Back to cited text no. 16
Abbott PV, Heithersay GS, Hume WR. Release and diffusion through human tooth rootsIn vitro of corticosteroid and tetracycline trace molecules from Ledermix paste. Endod Dent Traumatol 1988;4:55-62.  Back to cited text no. 17
Schroeder A. Ledermix 1962 – Ledermix today. Evaluation after 13 years of experience. Zahnarztl Prax 1975;26:195-6.  Back to cited text no. 18
Athanassiadis M, Jacobsen N, Parashos P. The effect of calcium hydroxide on the steroid component of Ledermix and Odontopaste. Int Endod J 2011;44:1162-9.  Back to cited text no. 19
Kishen A. Advanced therapeutic options for endodontic biofilms. Endod Topics 2012;22:99-123, 52.  Back to cited text no. 20
Diogenes A, Henry MA, Teixeira FB, Hargreaves KM: An update on clinical regenerative endodontics. Endod Topics 2013;28:2.  Back to cited text no. 21
Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, et al.In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J 1996;29:125-30.  Back to cited text no. 22
Windley W 3rd, Teixeira F, Levin L, Sigurdsson A, Trope M. Disinfection of immature teeth with a triple antibiotic paste. J Endod 2005;31:439-43.  Back to cited text no. 23
Bodrumlu E, Alaçam T, Semiz M. The antimicrobial and antifungal efficacy of tetracycline-integrated gutta-percha. Indian J Dent Res 2008;19:112-5.  Back to cited text no. 24
[PUBMED]  [Full text]  
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Hoelscher AA, Bahcall JK, Maki JS.In vitro evaluation of the antimicrobial effects of a root canal sealer-antibiotic combination against Enterococcusfaecalis. J Endod 2006;32:145-7.  Back to cited text no. 26
Trope M, Barnett F, Sigurdsson A, Chivian N. The role of Endodontics after Dental traumatic Injuries: Cohen's Pathways of the Pulp. 11th ed. Elsevier publishers, chapter 20; 2015;20. p. 758.  Back to cited text no. 27
Bryson EC, Levin L, Banchs F, Abbott PV, Trope M. Effect of immediate intracanal placement of Ledermix paste (R) on healing of replanted dog teeth after extended dry times. Dent Traumatol 2002;18:316-21.  Back to cited text no. 28
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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Uses of Antibiot...
Root Canal Irrigants
Intracanal Medic...
Regenerative End...
Medicated Sealers
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